Attachment S: Benefits Covered - ADULTS - AGE 21 AND OVER

Transcription

1 Diagnostic services include the oral examinations and selected radiographs needed to assess the oral health, diagnose oral pathology and develop an adequate treatment plan for the Participant s oral health. Periodic exams are not a covered benefit for Participants age 21 and over. Reimbursement for radiographs includes exposure of the radiograph, developing, mounting and radiographic interpretation. Reimbursement for multiple radiographs of the same tooth or area may be denied if Doral determines the number to be redundant, excessive or not in keeping with the federal policies relating to radiation exposure. Doral utilizes the guidelines published by the Department of Health and Human Services, Center for Devices and Radiological Health. These guidelines were developed in conjunction with the Food and Drug Administration and are described in Attachment J of this manual. If the total allowed amount for radiographs performed on a participant exceeds the allowed amount for procedure code D0210 (Complete Series), the submitted radiograph codes will be consolidated and paid as a Complete Series (D0210). The maximum reimbursement for a single date of service for radiographs shall be limited to the fee for a complete service. An initial examination is typically used when evaluating a patient comprehensively. It is a thorough evaluation and recording of the extraoral and intraoral hard and soft tissues. It may require interpretation of information acquired through additional diagnostic procedures. Additional diagnostic procedures should be reported separately. PLACE OF SERVICE (field #38 on 2002, 2004 ADA claim form) MUST BE INDICATED ON ALL CLAIMS. Diagnostic Code D0140 limited oral evaluation - problem focused 21 and older Limited emergency exam will only be covered when performed in conjunction with treatment to address an emergency situation. An emergency will be defined as treatment medically necessary to treat pain, infection, swelling, uncontrolled bleeding or traumatic injury. t allowed with D9110. D0150 comprehensive oral evaluation - new or established patient 21 and older Once per lifetime. One comprehensive exam per patient per dentist or dental group per lifetime. of the emergency and description of services provided with claim. Page 1 of 32

2 D0210 intraoral - complete series (including bitewings) Diagnostic 21 and older One per 36 months. D0220 intraoral - periapical - first film 21 and older Maximum of one (1) per day per patient per dentist or dental group. D0230 intraoral - periapical - each additional film 21 and older Maximum reimbursement for a single date of service for radiographs limited to fee for Complete Series (D0210). D0270 bitewing - single film 21 and older Maximum reimbursement for a single date of service for radiographs limited to fee for Complete Series (D0210). D0272 bitewings - two films 21 and older Maximum reimbursement for a single date of service for radiographs limited to fee for Complete Series (D0210). Page 2 of 32

3 Diagnostic D0274 bitewings - four films 21 and older Maximum reimbursement for a single date of service for radiographs limited to fee for Complete Series (D0210). D0277 vertical bitewings - 7 to 8 films 21 and older Maximum reimbursement for a single date of service for radiographs limited to fee for Complete Series (D0210). D0330 panoramic film 21 and older One per 36 months. Maximum reimbursement for a single date of service for radiographs limited to fee for Complete Series (D0210). Page 3 of 32

4 Restorative services (amalgams and composites) are provided to remove decay and restore dental structures (teeth) to a reasonable condition. Payment is made for restorative services based on the number of surfaces restored, not on the number of restorations per surface, or per tooth, per day. Bases, cements, liners, pulp caps, bonding agents and local anesthetic are included in the restorative service fees and are not reimbursed separately. Restorations are expected to last a reasonable amount of time. Repeated unexplained failures will result in review by Peer Review and may necessitate removal of the dentist from the panel. Restorative Code D2140 amalgam - one surface, primary or permanent 21 and older Teeth 1 through 32, A through T D2150 amalgam - two surfaces, primary or permanent 21 and older Teeth 1 through 32, A through T D2160 amalgam - three surfaces, primary or permanent 21 and older Teeth 1 through 32, A through T D2161 amalgam - four or more surfaces, primary or permanent 21 and older Teeth 1 through 32, A through T Page 4 of 32

5 D2330 resin-based composite - one surface, anterior Restorative 21 and older Teeth 6-11, 22-27, C - H, M - R D2331 resin-based composite - two surfaces, anterior 21 and older Teeth 6-11, 22-27, C - H, M - R D2332 resin-based composite - three surfaces, anterior 21 and older Teeth 6-11, 22-27, C - H, M - R D2335 resin-based composite - four or more surfaces or involving incisal angle (anterior) 21 and older Teeth 6-11, 22-27, C - H, M - R D2391 resin-based composite - one surface, posterior 21 and older Teeth 1-5, 12-21, 28-32, A, B, I, J, K, L, S, T Page 5 of 32

6 D2392 resin-based composite - two surfaces, posterior Restorative 21 and older Teeth 1-5, 12-21, 28-32, A, B, I, J, K, L, S, T D2393 resin-based composite - three surfaces, posterior 21 and older Teeth 1-5, 12-21, 28-32, A, B, I, J, K, L, S, T D2394 resin-based composite - four or more surfaces, posterior 21 and older Teeth 1-5, 12-21, 28-32, A, B, I, J, K, L, S, T D2740 crown porcelain/ceramic substrate 21 and older Teeth 4-13, Yes One per 60 months. Pre-operative radiographs. D2750 crown - porcelain fused to high noble metal 21 and older Teeth 4-13, Yes One per 60 months. Pre-operative radiographs. Page 6 of 32

7 D2751 crown - porcelain fused to predominantly base metal Restorative 21 and older Teeth 4-13, Yes One per 60 months. Pre-operative radiographs. D2752 crown - porcelain fused to noble metal 21 and older Teeth 4-13, Yes One per 60 months. Pre-operative radiographs. D2790 crown - full cast high noble metal 21 and older Teeth 1 through 32 Yes One per 60 months. Pre-operative radiographs. D2791 crown - full cast predominantly base metal 21 and older Teeth 1 through 32 Yes One per 60 months. Pre-operative radiographs. D2792 crown - full cast noble metal 21 and older Teeth 1 through 32 Yes One per 60 months. Pre-operative radiographs. Page 7 of 32

8 D2910 recement inlay, onlay or partial coverage restoration Restorative 21 and older Teeth 1 through 32 D2915 recement cast or prefabricated post and core 21 and older Teeth 1 through 32 D2920 recement crown 21 and older Teeth 1 through 32, A through T D2931 prefabricated stainless steel crown - permanent tooth 21 and older Teeth 1 through 32 Yes required for two (2) or more crowns. t compensated with construction of permanent crown. Pre-operative radiographs. D2932 prefabricated resin crown 21 and older Teeth 6-11, 22-27, C - H, M - R Yes required for two (2) or more crowns. Pre-operative radiographs. Page 8 of 32

9 Restorative D2940 sedative filling 21 and older Teeth 1 through 32, A through T D2951 pin retention - per tooth, in addition to restoration 21 and older Teeth 1 through 32 D2954 prefabricated post and core in addition to crown 21 and older Teeth 1 through 32 Yes Endodontic fill radiograph. Page 9 of 32

10 Endodontic services are provided to retain teeth through root canal therapy made necessary due to trauma or carious exposure. The following guidelines must be followed when providing endodontic services: Pulpotomies will only be covered on primary teeth with no evidence of internal resorption, furcation or periapical pathologic involvement. The standard of acceptability employed for endodontic procedures requires that the canal(s) be completely filled apically and laterally. In cases where the root canal filling does not meet Doral s treatment standards, Doral can require the procedure to be redone at no additional cost. Any reimbursement already made for an inadequate service may be recouped after the Doral Consultant reviews the circumstances. Root canal therapy for permanent teeth includes diagnosis, extirpation of the pulp, shaping and enlarging the canals, temporary fillings, filling and obliteration of root canal(s), and progress radiographs. The fee does not include the final restoration. Root canals and pulpotomies may not be covered in the following situations: * Root resorption has started and exfoliation is imminent * Gross periapical or periodontal pathosis is demonstrated radiographically (caries to the furcation, or subcrestal deeming the tooth non-restorable) * The general oral condition does not justify root canal therapy due to the loss of arch integrity * Tooth does not demonstrate 50% bone support * Tooth demonstrates active untreated periodontal disease Endodontics Code D3310 anterior canal (excluding final restoration) 21 and older Teeth 6-11, Once per lifetime. Page 10 of 32

11 Provisions for removable prosthesis included initial placement when masticatory function is impaired or when existing prosthesis is at least five years old and unserviceable. Payment for dentures includes any necessary adjustments, repairs or relines necessary during the six - (6) month period following delivery of a new prosthesis. Relines are covered once every 24 months. The reimbursement for an incomplete denture service (non-delivery) will be limited to the out-of-pocket costs as documented by a copy of the lab bill. THE DATE OF PLACEMENT MUST BE USED AS THE DATE OF SERVICE WHEN SUBMITTING FOR PAYMENT OF DENTURES. Extractions and other procedures necessary prior to denture placement must be rendered and paid before dentures will be reimbursed. If immediate dentures, extractions must be rendered and billed with the same date of service as placement of the immediate dentures. In situations where it is impractical to obtain pre-operative radiographs on a patient in a nursing home or long term care facility, a written narrative by the dentist stating that the patient is in a physical and mental state sufficient to function with full dentures is required for authorization. Denture benefits for patients with the following medical conditions will not be considered for coverage: * Patients on feeding tubes * Post CVA patients with decreased facial muscle tone * Patients in a coma * Patients with diminished mental capacities that could not function with dentures * Patients who do not desire dentures * Advanced terminal patients Prosthodontics, removeable Code D5110 complete denture - maxillary 21 and older Yes One per 60 months. (D5110 or D5130). Pre-operative full mouth radiographs. Date of prior placement (if applicable). D5120 complete denture - mandibular 21 and older Yes One per 60 months. (D5120 or D5140). Pre-operative full mouth radiographs. Date of prior placement (if applicable). Page 11 of 32

12 Prosthodontics, removeable D5130 immediate denture - maxillary 21 and older Yes One per 60 months. (D5110 or D5130). Pre-operative full mouth radiographs. D5140 immediate denture - mandibular 21 and older Yes One per 60 months. (D5120 or D5140). Pre-operative full mouth radiographs. D5510 repair broken complete denture base 21 and older Upper Arch 01 (UA) or Lower Arch 02 (LA) D5520 replace missing or broken teeth - complete denture (each tooth) 21 and older Teeth 1 through 32 D5610 repair resin denture base 21 and older Upper Arch 01 (UA) or Lower Arch 02 (LA) Page 12 of 32

13 Prosthodontics, removeable Code D5620 repair cast framework 21 and older Upper Arch 01 (UA) or Lower Arch 02 (LA) D5630 repair or replace broken clasp 21 and older D5640 replace broken teeth - per tooth 21 and older Teeth 1 through 32 D5650 add tooth to existing partial denture 21 and older Teeth 1 through 32 D5730 reline complete maxillary denture (chairside) 21 and older Yes One per 24 months. Date of denture placement. Page 13 of 32

14 D5731 reline complete mandibular denture (chairside) Prosthodontics, removeable 21 and older Yes One per 24 months. Date of denture placement. D5740 reline maxillary partial denture (chairside) 21 and older Yes One per 24 months. Date of denture placement. D5741 reline mandibular partial denture (chairside) 21 and older Yes One per 24 months. Date of denture placement. D5750 reline complete maxillary denture (laboratory) 21 and older Yes One per 24 months. Date of denture placement. D5751 reline complete mandibular denture (laboratory) 21 and older Yes One per 24 months. Date of denture placement. Page 14 of 32

15 Prosthodontics, removeable D5760 reline maxillary partial denture (laboratory) 21 and older Yes One per 24 months. Date of denture placement. D5761 reline mandibular partial denture (laboratory) 21 and older Yes One per 24 months. Date of denture placement. Page 15 of 32

16 Code Maxillofacial Prosthetics D5911 facial moulage (sectional) 21 and older Yes D5912 facial moulage (complete) 21 and older Yes D5913 nasal prosthesis 21 and older Yes D5914 auricular prosthesis 21 and older Yes D5915 orbital prosthesis 21 and older Yes Page 16 of 32

17 Maxillofacial Prosthetics D5916 ocular prosthesis 21 and older Yes D5919 facial prosthesis 21 and older Yes D5922 nasal septal prosthesis 21 and older Yes D5923 ocular prosthesis, interim 21 and older Yes D5924 cranial prosthesis 21 and older Yes Page 17 of 32

18 Maxillofacial Prosthetics D5925 facial augmentation implant prosthesis 21 and older Yes D5926 nasal prosthesis, replacement 21 and older Yes D5927 auricular prosthesis, replacement 21 and older Yes D5928 orbital prosthesis, replacement 21 and older Yes D5929 facial prosthesis, replacement 21 and older Yes Page 18 of 32

19 Maxillofacial Prosthetics D5931 obturator prosthesis, surgical 21 and older Yes D5932 obturator prosthesis, definitive 21 and older Yes D5933 obturator prosthesis, modification 21 and older Yes D5934 mandibular resection prosthesis with guide flange 21 and older Yes D5935 mandibular resection prosthesis without guide flange 21 and older Yes Page 19 of 32

20 Maxillofacial Prosthetics D5936 obturator prosthesis, interim 21 and older Yes D5937 trismus appliance (not for TMD treatment) 21 and older Yes t for TMD Treatment. D5951 feeding aid 21 and older Yes D5953 speech aid prosthesis, adult 21 and older Yes D5954 palatal augmentation prosthesis 21 and older Yes Page 20 of 32

21 Maxillofacial Prosthetics D5955 palatal lift prosthesis, definitive 21 and older Yes D5958 palatal lift prosthesis, interim 21 and older Yes D5959 palatal lift prosthesis, modification 21 and older Yes D5960 speech aid prosthesis, modification 21 and older Yes D5982 surgical stent 21 and older Yes Page 21 of 32

22 Maxillofacial Prosthetics D5983 radiation carrier 21 and older Yes D5984 radiation shield 21 and older Yes D5985 radiation cone locator 21 and older Yes D5986 fluoride gel carrier 21 and older Yes D5987 commissure splint 21 and older Yes Page 22 of 32

23 Maxillofacial Prosthetics D5988 surgical splint 21 and older Yes D5999 unspecified maxillofacial prosthesis, by report 21 and older Yes Page 23 of 32

24 Code Prosthodontics, fixed D6930 recement fixed partial denture 21 and older Page 24 of 32

25 Prophylactic removal of multiple asymptomatic teeth, or teeth free from pathology is not a covered benefit. Extraction of deciduous teeth that radiographically appear to be near imminent exfoliation is not a covered benefit. Reimbursement includes local anesthesia and post-operative care. Claims for all oral surgical procedures except simple, non-surgical extractions or for procedure code D7210 must include a pre-operative radiograph to be considered for reimbursement. Simple and surgical extractions are covered. Local anesthesia and routine post-operative care are included in the fees and will not be reimbursed separately. Erupted surgical extractions are defined as extractions requiring elevation of a mucoperiosteal flap and removal of bone, and/or section of the tooth and closure. Tuberosity reductions are not payable in conjunction with extractions or alveolectomy in the same quadrant. For oral surgery performed as part of emergency care, the requirement for prior authorization is waived. Service will still be subject to retrospective review. Emergency care is defined as treatment of pain, infection, swelling, uncontrolled bleeding, or traumatic injury. Oral Surgery Code D7140 extraction - erupted tooth or exposed root (elevation and/or forceps removal) 21 and older Teeth 1 through 32, 51 through 82 (SN), A through T, AS through TS (SN) D7210 surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth 21 and older Teeth 1 through 32, 51 through Prophylatic removal of asymptomatic tooth or 82 (SN), A through T, AS tooth free from pathology is not a covered benefit. through TS (SN) Pre-operative radiographs. Page 25 of 32

26 Oral Surgery D7220 removal of impacted tooth - soft tissue 21 and older Teeth 1 through 32, 51 through Yes Prophylatic removal of asymptomatic tooth or 82 (SN) tooth free from pathology is not a covered benefit. Pre-operative radiographs. D7230 removal of impacted tooth - partially bony 21 and older Teeth 1 through 32, 51 through Yes Prophylatic removal of asymptomatic tooth or 82 (SN) tooth free from pathology is not a covered benefit. Pre-operative radiographs. D7240 removal of impacted tooth - completely bony 21 and older Teeth 1 through 32, 51 through Yes Prophylatic removal of asymptomatic tooth or 82 (SN) tooth free from pathology is not a covered benefit. Pre-operative radiographs. D7250 surgical removal of residual tooth roots (cutting procedure) 21 and older Teeth 1 through 32, 51 through Yes Prophylatic removal of asymptomatic tooth or 82 (SN), A through T, AS tooth free from pathology is not a covered benefit. through TS (SN) Pre-operative radiographs. D7450 removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm 21 and older Yes Copy of pathology report with claim. Page 26 of 32

27 D7451 removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm Oral Surgery 21 and older Yes Copy of pathology report with claim. D7460 removal of benign non-odontogenic cyst or tumor - lesion diameter up to 1.25 cm 21 and older Yes Copy of pathology report with claim. D7461 removal of benign non-odontogenic cyst or tumor - lesion diameter greater than 1.25 cm 21 and older Yes Copy of pathology report with claim. D7510 incision and drainage of abscess - intraoral soft tissue 21 and older Yes Either D7510 or D7511 on date of service. Pre-operative radiographs and narrative with claim. D7511 incision and drainage - intraoral - complicated 21 and older Yes Includes drainage of multiple fascial spaces. Either D7510 or D7511 on date of service. Pre-operative radiographs and narrative with claim. Page 27 of 32

28 D7610 maxilla - open reduction (teeth immobilized, if present) Oral Surgery 21 and older Yes Pre-operative radiographs and accident narrative details with claim. D7620 maxilla - closed reduction (teeth immobilized, if present) 21 and older Yes Pre-operative radiographs and accident narrative details with claim. D7630 mandible - open reduction (teeth immobilized, if present) 21 and older Yes Pre-operative radiographs and accident narrative details with claim. D7640 mandible - closed reduction (teeth immobilized, if present) 21 and older Yes Pre-operative radiographs and accident narrative details with claim. D7710 maxilla - open reduction 21 and older Yes Pre-operative radiographs and accident narrative details with claim. Page 28 of 32

29 Oral Surgery D7720 maxilla - closed reduction 21 and older Yes Pre-operative radiographs and accident narrative details with claim. D7730 mandible - open reduction 21 and older Yes Pre-operative radiographs and accident narrative details with claim. D7740 mandible - closed reduction 21 and older Yes Pre-operative radiographs and accident narrative details with claim. D7810 open reduction of dislocation 21 and older Yes Narrative of medical necessity with claim. D7820 closed reduction of dislocation 21 and older Yes Narrative of medical necessity with claim. Page 29 of 32

30 Adjunctive general services include general anesthesia, intravenous sedation, nitrous oxide analgesia, consultations and various drugs and medicaments, and emergency services provided for relief of dental pain. Procedure code D9110 palliative treatment is to be used to bill for minor palliative procedures when the only other procedure code billed for is a diagnostic radiograph. If any other services (filling, endodontics, oral surgery etc.) are billed for on the same day, the palliative treatment code will be denied. Intravenous sedation and general anesthesia will only be a covered service for participating dentists that hold current certification and licensure per state and federal guidelines. Requests for intravenous sedation and general anesthesia will be reviewed on a case by case basis. A case will be covered for Participants with physical or mental health problems of such severity that treatment can not be reasonably attempted without the use of intravenous sedation or general anesthesia. Intravenous sedation or general anesthesia may be allowed when a surgical procedure is being rendered. Claims for intravenous sedation and general anesthesia must include a narrative of medical necessity. Acceptable conditions include: * Toxicity to local anesthesia supported by documentation; * Severe mental retardation; * Severe physical disability; * Uncontrolled management problem; * Extensive or complicated surgical procedures; * Failure of local anesthesia; * Documented medical complications; and * Acute infection that would preclude the efficacy of local anesthesia. For cases requiring intravenous sedation or general anesthesia, Providers must document the following in the Participant's chart for appropriate psychosomatic disorders: diagnosis, description of past evidence of situational anxiety or uncontrolledbehaviors, and in the case of referral due to uncontrolled behavior, the name of the referring dentist or provider group. Apprehension alone is not typically considered medically necessary. Doral or the IDPA may elect to perform chart audits on these services. Services not documented as required may be denied for payment. The procedures will only be reimbursed for once per day regardless of the length of time it takes to complete the procedure. General anesthesia, intravenous sedation, and nitrous oxide are only covered in conjunction with a covered dental procedure. Payment for any one of these services precludes payment for the remaining procedure codes. Payment for general anesthesia or intravenous sedation includes any other drugs administered on the same day. Reimbursement for local anesthesia is included in the fee for the procedures. Procedure code D9230 nitrous oxide, is a covered service for Participants who are mentally or physically challenged, or otherwise present with special management needs. Only claims for nitrous oxide with documented medical necessity will be considered for payment. Medical necessity for the use of nitrous oxide would be broadly defined as some condition specific to the particular treatment situation that would preclude the performance of necessary dental treatment, with the use of a local anesthetic alone. Situations for nitrous oxide will be reviewed for coverage on a case by case basis. Page 30 of 32

31 Procedure code D9310 consultation, will only be reimbursed to a dentist other than the one providing definitive treatment. A consultation includes an examination and evaluation of the patient, and a written report from the consultant to the treating dentist. When billing for a consultation, a copy of the written report must be attached. When the consulting dentist also performs services reimbursement to that dentist will be limited to the actual services performed. There will not be a separate reimbursement for a consultation. Procedure code D9999 is to be utilized to submit a request for reimbursement for a dental service not otherwise described herein. Request should include a description of the service, medical necessity, a proposed fee and any pertinent radiographs. Adjunctive General Code D9110 palliative (emergency) treatment of dental pain - minor procedure 21 and older t covered wth D0140 on same date of service. D9220 deep sedation/general anesthesia - first 30 minutes 21 and older Yes Narrative of medical necessity. All inclusive fee - t limited to first 30 minutes. D9230 analgesia, anxiolysis, inhalation of nitrous oxide 21 and older Yes D9241 intravenous conscious sedation/analgesia - first 30 minutes 21 and older Yes Narrative of medical necessity. All inclusive fee - t limited to first 30 minutes. Page 31 of 32

32 D9310 consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment) Adjunctive General 21 and older Narrative of medical necessity shall be maintained in patient records. D9610 therapeutic drug injection, by report 21 and older Yes Narrative of medical necessity. Name of drug and amount administered. D9630 other drugs and/or medicaments, by report 21 and older Yes Narrative of medical necessity. Name of drug and amount administered. D9999 unspecified adjunctive procedure, by report 21 and older Yes of service and narrative of medical necessity. Page 32 of 32